Can an ulcerated subclavian plaque cause chest pain?

Can Ulcerated Subclavian Plaque Cause Chest Pain?

Yes, ulcerated subclavian plaque can cause chest pain through several mechanisms, including subclavian steal syndrome, compromised blood flow to coronary bypass grafts, and direct vascular symptoms. 1, 2

Pathophysiological Mechanisms

Direct Mechanisms

• Vascular Pain: Ulcerated plaques in the subclavian artery can directly cause chest discomfort due to arterial wall inflammation and irritation
• Subclavian Steal Syndrome: When proximal subclavian artery becomes stenotic or occluded due to ulcerated plaque, it can cause:
  • Flow reversal in the vertebral artery
  • Reduced basilar artery perfusion
  • Posterior cerebrovascular insufficiency
  • Symptoms typically aggravated by exercising the ipsilateral arm 1

Indirect Mechanisms

• Coronary Subclavian Steal Syndrome: In patients with previous CABG using LIMA (Left Internal Mammary Artery) to LAD (Left Anterior Descending), subclavian stenosis proximal to the LIMA origin can cause:
  • Diversion of blood flow from the coronary circulation
  • Myocardial ischemia presenting as unstable angina or acute coronary syndrome 3
  • Particularly concerning in patients with existing coronary disease 4

Clinical Presentation

Symptoms

• Chest pain that may mimic angina pectoris
• Pain may be exacerbated by arm exercise on the affected side
• Associated symptoms may include:
  • Upper extremity claudication or fatigue
  • Paresthesia
  • Dizziness or vertigo (with vertebrobasilar insufficiency) 1

Physical Examination Findings

• Periclavicular or infraclavicular bruit
• Asymmetry between left and right arm blood pressure measurements
• Blood pressure tends to fall further in the affected limb after arm exercise 1

Diagnostic Approach

Initial Assessment

• Focused cardiovascular examination to differentiate from other serious causes of chest pain 1
• Check for blood pressure differences between arms (>10 mmHg difference suggests subclavian stenosis) 5
• Listen for bruits in the supraclavicular region

Imaging

• Duplex Ultrasonography: First-line imaging to identify reversal of flow in vertebral artery and assess subclavian stenosis 5
• CT Angiography: Provides detailed anatomical information about plaque characteristics and degree of stenosis
• MR Angiography: Useful for plaque characterization without radiation exposure
• Digital Subtraction Angiography: Gold standard for grading stenosis severity 5

Management

Medical Management

• Antiplatelet therapy unless contraindicated 2
• Risk factor modification (hypertension, diabetes, smoking cessation) 6

Revascularization

For symptomatic patients with chest pain related to subclavian stenosis:

• Endovascular treatment:

  • Percutaneous angioplasty and stenting is reasonable for patients with symptomatic ischemia 1
  • Preferred in high-risk surgical patients

• Surgical options:

  • Extra-anatomic bypass (carotid-subclavian, axilloaxillary)
  • Subclavian-carotid arterial transposition 1

Special Considerations

Post-CABG Patients

• In patients with previous LIMA-to-LAD bypass, subclavian stenosis requires urgent attention to prevent coronary subclavian steal syndrome 3
• Consider revascularization even in asymptomatic patients when the ipsilateral internal mammary artery is required as a conduit for myocardial revascularization 1

Correlation with Coronary Disease

• Patients with both carotid and subclavian atherosclerotic plaques have higher incidence of coronary artery disease than those with carotid plaques alone 7
• The presence of subclavian calcification is significantly associated with calcification in other vascular beds 6

In conclusion, ulcerated subclavian plaque is an important but often overlooked cause of chest pain that should be considered in the differential diagnosis, particularly in patients with risk factors for atherosclerosis or previous coronary bypass surgery.